Mithila Rajya Nirman Sena

(Membership Form (Ward No./Panchayat: Name of the proposed member: Fathers Name: Mothers Name: Address (Mithila): Address (If living out of Mithila):
Note: Both addresses are required if living out of Mithila or permanently settled

Assembly:

Loksabha:

Contact Details Telephone No. (Landline): Mobile Nos.: Email Address: Socila Medias Ids (1): Socila Medias Ids (2):

References 1. Relative (Not living in your village or town with Name, Address and Mobile No.:

2. Relative (Not living in your village or town with Name, Address and Mobile No.:

3. Relative (Not living in your village or town with Name, Address and Mobile No.:

Membership Fee Paid in Cash: Rs. Cheque No.: Rs. Bank Name: Date:

(Payers Singature)

(Receivers Singature with Name and Designation)

Membership Fee: 151.00 (Yearly), 1100.00 (Lifetime), You are free to donate as much as you can.

For Office Use Only Unique Membership No. Allocated: MRNS/Fbd/2013/ Feedback From the Faridabad District Council:

Mithila Rajya Nirman Sena, Nagar House, Purani Kheda, Dhiraj Nagar, Sector-30, Faridabad Contact: 09213000762, 09136200565, 09910012251